{"id":136,"date":"2021-05-20T13:59:14","date_gmt":"2021-05-20T13:59:14","guid":{"rendered":"https:\/\/duraanorthodontics.co.za\/afr\/?page_id=136"},"modified":"2021-07-14T06:33:01","modified_gmt":"2021-07-14T06:33:01","slug":"pre-first-visit-health-history-form","status":"publish","type":"page","link":"https:\/\/duraanorthodontics.co.za\/afr\/pre-first-visit-health-history-form\/","title":{"rendered":"Pre-first-visit Health History Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_6 1_6 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-0{width:16.666666666667% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 11.52%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 11.52%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:16.666666666667% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 11.52%;margin-left 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.fusion-form-image-select .fusion-form-input:checked + label,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-image-select .fusion-form-input:hover + label,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-checkbox input:focus + label:before,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-radio input:focus + label:before,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-image-select .fusion-form-input:focus + label{border-color:#5b4ad4;}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-radio input:hover:not(:checked) + label:before,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-checkbox input:hover:not(:checked) + label:before,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-image-select .fusion-form-input:hover:not(:checked) + label,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field 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i{color:rgba(91,74,212,0.5);}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-checkbox input:checked + label:after,.fusion-form-135.fusion-form-form-wrapper .fusion-form-field .fusion-form-radio input:checked + label:after{background:#5b4ad4;}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field input[type=range]::-ms-track{background:#5b4ad4;}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field input[type=range]::-webkit-slider-thumb{background:#5b4ad4;}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field input[type=range]::-moz-range-thumb{background:#5b4ad4;}.fusion-form-135.fusion-form-form-wrapper .fusion-form-field input[type=range]::-ms-thumb{background:#5b4ad4;}<\/style><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-135\" data-form-id=\"135\"><form action=\"https:\/\/duraanorthodontics.co.za\/afr\/pre-first-visit-health-history-form\/\" method=\"post\" class=\"fusion-form fusion-form-135\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1\" style=\"text-align:left;line-height:1;\"><h2>Patient Biographical Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-3{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-3{width:50% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"middle_name\" id=\"middle_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Middle name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:50% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-5{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:50% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"nickname\" id=\"nickname\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Nickname*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-6{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-6{width:50% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"135\"><input autocomplete=\"no\" type=\"date\" tabindex=\"\" id=\"birthdate\" name=\"birthdate\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Birthdate*\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-7{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-7{width:50% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" data-form-id=\"135\"><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"gender\" name=\"gender\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Gender<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-8{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:50% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-1{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: #f4f4f4;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 4px;border-color:#5745c8;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-9{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:50% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"address_2\" id=\"address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-10{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-10{width:50% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-11{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-11{width:50% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"postal_code\" id=\"postal_code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-12{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-12{width:50% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-2{ padding-top : 20px;margin-top : 25px;padding-right : 35px;padding-bottom : 20px;margin-bottom : 25px;padding-left : 35px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-3 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"phone-number\" name=\"main_phone\" id=\"main_phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Main phone*\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-13{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-13{width:50% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"phone-number\" name=\"second_phone\" id=\"second_phone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"2nd\/Cell phone\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-14{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-14{width:50% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Email*\" data-holds-private-data=\"false\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-15{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"parent_guardian\" id=\"parent_guardian\" value=\"\"  class=\"fusion-form-input\" placeholder=\"If patient is a minor, give parent&#039;s or guardian&#039;s name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"pasient_residence\" id=\"pasient_residence\" value=\"\"  class=\"fusion-form-input\" placeholder=\"If patient is a minor, who does the patient live with?\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"135\"><textarea cols=\"40\" rows=\"4\" tabindex=\"\" id=\"friends_family\" name=\"friends_family\" class=\"fusion-form-input\" placeholder=\"Please list the names of any friends or family in the practice\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"thanks_to\" id=\"thanks_to\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Whom may we thank for referring you to our practice?\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-16{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-16 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-3{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-4 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-2\" style=\"text-align:left;line-height:1;\"><h2>Financial Party Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-17{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-17 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-patient_financially_responsible-1-0\" type=\"checkbox\" value=\"Check if the patient is also the person who will be financially responsible for treatment.\" name=\"patient_financially_responsible[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-patient_financially_responsible-1-0\">Check if the patient is also the person who will be financially responsible for treatment.<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-18{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-18 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"First name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-19{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-19 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-19{width:50% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Last name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-20{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-20 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-20{width:50% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-20{width:100% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"marital_status\" id=\"marital_status\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Marital Status\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-21{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-21 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-21{width:50% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-21{width:100% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-22 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"relation_to_patient\" id=\"relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-22{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-22 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-22{width:50% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-23 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"marital_status\" id=\"marital_status\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Marital Status\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-23{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-23 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-23{width:50% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-24 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"135\"><input autocomplete=\"no\" type=\"date\" tabindex=\"\" id=\"birthdate\" name=\"birthdate\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Birthdate*\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-24{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-24 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-24{width:50% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-4{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-5 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: #f4f4f4;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 4px;border-color:#5745c8;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-25 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-25{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-25 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-25{width:50% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-26 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"address_2\" id=\"address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-26{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-26 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-26{width:50% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-27 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-27{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-27 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-27{width:50% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-28 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"postal_code\" id=\"postal_code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-28{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-28 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-28{width:50% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-5{ padding-top : 20px;margin-top : 25px;padding-right : 35px;padding-bottom : 20px;margin-bottom : 25px;padding-left : 35px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-6 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-29 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Email*\" data-holds-private-data=\"false\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-29{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-29 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-30 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"phone-number\" name=\"main_phone\" id=\"main_phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Main phone*\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-30{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-30 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-30{width:50% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-31 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"phone-number\" name=\"second_phone\" id=\"second_phone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"2nd\/Cell phone\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-31{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-31 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-31{width:50% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-31{width:100% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-32 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"occupation\" id=\"occupation\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Occupation*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#e2e2e2;border-top-width:1px;\"><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-32{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-32 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-32{width:100% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-32{width:100% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-6{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-7 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-33 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"spouse_first_name\" id=\"spouse_first_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Spouse or Other Parent&#039;s First Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-33{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-33 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-33{width:50% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-34 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"spouse_middle_initial\" id=\"spouse_middle_initial\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Middle Initial\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-34{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-34 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-34{width:50% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-35 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"spouse_last_name\" id=\"spouse_last_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Last Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-35{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-35 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-35{width:50% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-36 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"spouse_relation_to_patient\" id=\"spouse_relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-36{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-36 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-36{width:50% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-37 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"spouse_id\" id=\"spouse_id\" value=\"\"  class=\"fusion-form-input\" placeholder=\"ID Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-37{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-37 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-37{width:50% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-7{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-8 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-38 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-3\" style=\"text-align:left;line-height:1;\"><h2>Dental Insurance Information<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-38{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-38 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-39 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"policy_holder\" id=\"policy_holder\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Policy Holder&#039;s Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-39{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-39 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-39{width:50% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-40 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"policy_holder_relation_to_patient\" id=\"policy_holder_relation_to_patient\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Relation to Patient\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-40{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-40 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-40{width:50% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-41 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"insurance_company\" id=\"insurance_company\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Company\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-41{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-41 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-41{width:50% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-42 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"subscriber_id\" id=\"subscriber_id\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Subscriber ID #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-42{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-42 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-42{width:50% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-43 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"insurance_plan\" id=\"insurance_plan\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Plan\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-43{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-43 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-43{width:50% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-44 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"insurance_telephone\" id=\"insurance_telephone\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insurance Co. Phone Number\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-44{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-44 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-44{width:50% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-8{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-9 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-45 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-4\" style=\"text-align:left;line-height:1;\"><h2>Dental History<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-45{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-45 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-46 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"135\"><input type=\"text\" name=\"dentist_name\" id=\"dentist_name\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Dentist Name\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-46{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-46 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-46{width:50% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-47 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" data-form-id=\"135\"><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"check_up_frequency\" name=\"check_up_frequency\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Check-up Frequency<\/option><option value=\"6 months\" >6 months<\/option><option value=\"12 months\" >12 months<\/option><option value=\"18 months\" >18 months<\/option><option value=\"24 months\" >24 months<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-47{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-47 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-47{width:50% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-48 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"135\"><input autocomplete=\"no\" type=\"date\" tabindex=\"\" id=\"last_dental_visit\" name=\"last_dental_visit\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Last Dental Visit\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-48{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-48 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-48{width:50% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-48{width:100% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-49 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Has the patient had an orthodontic consultation or treatment?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-orthodontic_consultation-1-0\" type=\"radio\" value=\"Yes\" name=\"orthodontic_consultation\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-orthodontic_consultation-1-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-orthodontic_consultation-1-1\" type=\"radio\" value=\"No\" name=\"orthodontic_consultation\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-orthodontic_consultation-1-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"135\"><input autocomplete=\"no\" type=\"date\" tabindex=\"\" id=\"date_of_orthodontic_consultation\" name=\"date_of_orthodontic_consultation\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"If so, when?\"autocomplete=\"no\"\/><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Does the patient need to premedicate prior to dental visit?<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-premedicate_required-2-0\" type=\"radio\" value=\"Yes\" name=\"premedicate_required\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-premedicate_required-2-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-premedicate_required-2-1\" type=\"radio\" value=\"No\" name=\"premedicate_required\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-premedicate_required-2-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"135\"><textarea cols=\"40\" rows=\"4\" tabindex=\"\" id=\"main_orthodontic_concern\" name=\"main_orthodontic_concern\" class=\"fusion-form-input\" placeholder=\"What is the patient&#039;s main orthodontic concern?\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-49{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-49 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-49{width:100% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-49{width:100% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-9{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-10 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-50 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-5\" style=\"text-align:left;line-height:1;\"><h2>Patient Motivation for Orthodontic Treatment<\/h2>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-50{width:100% !important;margin-top : 20px;margin-bottom : 0px;}.fusion-builder-column-50 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-50{width:100% !important;order : 0;}.fusion-builder-column-50 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-50{width:100% !important;order : 0;}.fusion-builder-column-50 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-51 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-straighten_front_teeth-3-0\" type=\"radio\" value=\"Straighten Front Teeth\" name=\"straighten_front_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-straighten_front_teeth-3-0\">Straighten Front Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-4-0\" type=\"radio\" value=\"Upper\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-4-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-4-1\" type=\"radio\" value=\"Lower\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-4-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-front_teeth_position-4-2\" type=\"radio\" value=\"Both\" name=\"front_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-front_teeth_position-4-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-51{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-51 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-51{width:100% !important;order : 0;}.fusion-builder-column-51 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-51{width:100% !important;order : 0;}.fusion-builder-column-51 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-52 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-straighten_back_teeth-5-0\" type=\"radio\" value=\"Straighten Back Teeth\" name=\"straighten_back_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-straighten_back_teeth-5-0\">Straighten Back Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-6-0\" type=\"radio\" value=\"Upper\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-6-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-6-1\" type=\"radio\" value=\"Lower\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-6-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-back_teeth_position-6-2\" type=\"radio\" value=\"Both\" name=\"back_teeth_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-back_teeth_position-6-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-52{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-52 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-52{width:100% !important;order : 0;}.fusion-builder-column-52 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-52{width:100% !important;order : 0;}.fusion-builder-column-52 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-53 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_upper_teeth-7-0\" type=\"radio\" value=\"Move Upper Teeth\" name=\"move_upper_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_teeth-7-0\">Move Upper Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_upper_teeth-8-0\" type=\"radio\" value=\"Forward\" name=\"move_upper_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_teeth-8-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_upper_teeth-8-1\" type=\"radio\" value=\"Backward\" name=\"move_upper_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_upper_teeth-8-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-53{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-53 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-53{width:100% !important;order : 0;}.fusion-builder-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-53{width:100% !important;order : 0;}.fusion-builder-column-53 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-54 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-move_lower_teeth-9-0\" type=\"radio\" value=\"Move Lower Teeth\" name=\"move_lower_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_teeth-9-0\">Move Lower Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_lower_teeth-10-0\" type=\"radio\" value=\"Forward\" name=\"move_lower_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_teeth-10-0\">Forward<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-move_lower_teeth-10-1\" type=\"radio\" value=\"Backward\" name=\"move_lower_teeth\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-move_lower_teeth-10-1\">Backward<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-54{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-54 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-54{width:100% !important;order : 0;}.fusion-builder-column-54 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-54{width:100% !important;order : 0;}.fusion-builder-column-54 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-55 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-eliminate_spaces-11-0\" type=\"radio\" value=\"Eliminate Spaces Between Teeth\" name=\"eliminate_spaces\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces-11-0\">Eliminate Spaces Between Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-12-0\" type=\"radio\" value=\"Upper\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-12-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-12-1\" type=\"radio\" value=\"Lower\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-12-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_spaces_position-12-2\" type=\"radio\" value=\"Both\" name=\"eliminate_spaces_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_spaces_position-12-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-55{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-55 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-55{width:100% !important;order : 0;}.fusion-builder-column-55 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-55{width:100% !important;order : 0;}.fusion-builder-column-55 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-56 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-eliminate_crowding-13-0\" type=\"radio\" value=\"Eliminate Crowding of Teeth\" name=\"eliminate_crowding\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding-13-0\">Eliminate Crowding of Teeth<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-14-0\" type=\"radio\" value=\"Upper\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-14-0\">Upper<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-14-1\" type=\"radio\" value=\"Lower\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-14-1\">Lower<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-eliminate_crowding_position-14-2\" type=\"radio\" value=\"Both\" name=\"eliminate_crowding_position\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-eliminate_crowding_position-14-2\">Both<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-56{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-56 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-56{width:100% !important;order : 0;}.fusion-builder-column-56 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-56{width:100% !important;order : 0;}.fusion-builder-column-56 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-57 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-upper_teeth_level-15-0\" type=\"radio\" value=\"Make Line of Upper Teeth More Level\" name=\"upper_teeth_level\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-upper_teeth_level-15-0\">Make Line of Upper Teeth More Level<\/label><\/div><\/fieldset><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-57{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-57 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-57{width:100% !important;order : 0;}.fusion-builder-column-57 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-57{width:100% !important;order : 0;}.fusion-builder-column-57 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-58 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" data-form-id=\"135\"><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-other-16-0\" type=\"radio\" value=\"Other\" name=\"other\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-other-16-0\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" data-form-id=\"135\"><textarea cols=\"40\" rows=\"4\" tabindex=\"\" id=\"other_details\" name=\"other_details\" class=\"fusion-form-input\" placeholder=\"Other\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-58{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-58 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-58{width:100% !important;order : 0;}.fusion-builder-column-58 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-58{width:100% !important;order : 0;}.fusion-builder-column-58 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-flex-container.fusion-builder-row-1-10{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-11 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-59 fusion_builder_column_1_5 1_5 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-recaptcha-field fusion-form-label-above\" data-form-id=\"135\">\t\t\t\t\t\t\t\t\t<div class=\"form-creator-recaptcha\" >\n\t\t\t\t\t\t\t\t\t\t\t\t\t<div\n\t\t\t\t\t\t\t\tid=\"g-recaptcha-135\"\n\t\t\t\t\t\t\t\tclass=\"fusion-form-recaptcha-v2\"\n\t\t\t\t\t\t\t\tdata-theme=\"light\"\n\t\t\t\t\t\t\t\tdata-sitekey=\"6Lctpz4bAAAAAOr8oAVuyCTKs76scmxmcPGFUSwi\"\n\t\t\t\t\t\t\t\tdata-tabindex=\"\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-59{width:20% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-59 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 9.6%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 9.6%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-59{width:20% !important;order : 0;}.fusion-builder-column-59 > .fusion-column-wrapper {margin-right : 9.6%;margin-left : 9.6%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-59{width:100% !important;order : 0;}.fusion-builder-column-59 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-60 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"form-submission-notices\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success alert-dismissable\" style=\"background-color:rgba(18,184,120,0.1);color:#12b878;border-color:#12b878;border-width:1px;margin-top:20px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-hidden=\"true\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error alert-dismissable\" style=\"background-color:rgba(219,75,104,0.1);color:#db4b68;border-color:#db4b68;border-width:1px;margin-top:20px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-hidden=\"true\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. 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